1995肠内营养的使用指南英文AGAWord文档格式.docx
《1995肠内营养的使用指南英文AGAWord文档格式.docx》由会员分享，可在线阅读，更多相关《1995肠内营养的使用指南英文AGAWord文档格式.docx（37页珍藏版）》请在冰豆网上搜索。
Thisdocumentprovidesgastroenterologistswithrecommendationsforprovidingsafeandeffectiveenteralnutritiontoadultpatients.ItisbasedontheAmericanGastroenterologicalAssociationTechnicalReviewonTubeFeedingforEnteralNutrition,1whichshouldbeconsultedforadditionalinformation.
IndicationsforTubeFeeding
Tubefeedingshouldbeconsideredforpatientswhocannotorwillnoteat,forpatientswhohaveafunctionalgut,andforwhomasafemethodofaccessispossible.
1.
Inmostpatients,nutritionsupportshouldbeinitiatedafter1-2weekswithoutnutrientintake.Enteralfeedingispreferabletoparenteraltherapyprovidedtherearenocontraindications,accesscanbeattainedsafely,andoralintakeisnotpossible.Insomepatients,combinationsofenteralandparenteralnutritionmaybenecessarytomeettheirnutritionalneeds.
2.
Mechanicalobstructionistheonlyabsolutecontraindicationtoenteralfeeding.
MethodsofFeeding
Alternativemethodsofdeliveringtubefeedingsexist,andthephysicianmustbefamiliarwiththeadvantagesandlimitationsrelativetoaspecificpatient.
Fortheshort-term（<
30days）,nasogastricornasoenterictubesarepreferredovergastrostomyorjejunostomytubes.
Tubesplacedpastthethirdportionoftheduodenum,andespeciallypasttheligamentofTreitz,areassociatedwithadecreasedriskofaspiration.
3.
Variousmethodsoftubeplacementmaybeusedatthebedside.Endoscopicallyorfluoroscopicallyguidedtubeplacementshouldbereservedforpatientsinwhombedsidetechniqueshavebeenunsuccessful.Prokineticdrugsgivenbeforeplacementmaybebeneficialinpositioningsmallernasoenterictubes（8Fand10F）beyondthepylorus.
4.
Intermittentgravityfeedingissufficientformostpatientswithnasogastricorgastrostomytubes.Pump-controlledinfusionsarerecommendedforjejunalfeedingsandforgastrostomyfeedingsgivenbycontinuousinfusiontodecreasegastroesophagealreflux.
5.
Withnasogastrictubefeeding,asingleelevatedresidualvolumeisanindicationtorechecktheresidualvolumein1hour;
however,thefeedingshouldnotautomaticallybestopped.
6.
Jejunalaccessisappropriateinpatientswithahistoryoftubefeeding-relatedaspirationpneumoniaorrefluxesophagitis.
PercutaneousGastrostomyPlacement
Whereasplacementofgastrostomyandjejunostomytubeshastraditionallybeenthepurviewofsurgeons,severaltechniqueshavebeendevelopedthathaveledtotheseproceduresbeingperformedbygastroenterologistsorradiologists.Eachhasitsownrisksandbenefitsand,sometimes,uniquecomplications.
Gastrostomytubesarejustifiedforpatientswhoneedtubefeedingformorethan30days.Thepatient'
sunderlyingdiseaseandavailableexpertisemustbeconsideredwhendecidingbetweentypesofplacement（operativeorpercutaneousendoscopicorradiologicalgastrostomy）.Thephysicianmustbefamiliarwithalternativeplacementmethodsandtubetypes,particularlywhentreatingpatientswithesophagealdiseasethatmaycomplicatestandardinsertiontechniques.
Forgastricaccessusingconscioussedation,percutaneousendoscopicgastrostomyisusuallypreferabletooperativegastrostomy.Thelatterrequiresmorerecoverytimeandismoreexpensive.Radiologicalgastrostomyplacement,dependingonanatomicindications,mayobviatetheneedforendoscopicprocedures.
Carefulattentiontotechniqueduringplacementandmonitoringofthepatientafterplacementareessentialtominimizecomplications.
ComplicationsofTubeFeeding
Tubefeedingisarelativelysafeprocedurewhosecomplicationsusuallycanbeavoidedormanaged.Inadditiontothecomplicationsofpercutaneoustubeplacement（e.g.,infection）,patientsmayexperienceaspiration,diarrhea,alterationsindrugabsorptionandmetabolism,andvariousmetabolicdisturbances.
Tolimittheriskofaspirationwithgastricfeeding,thefollowingprecautionsshouldbetaken:
raisetheheadofthepatient'
sbed30°
-45°
duringfeedingandfor1hourafter,useintermittentorcontinuousfeedingregimensratherthantherapidbolusmethod,gastricresidualsshouldbecheckedregularly,andallpatientsshouldbewatchedforsignsoffeedingintolerance.
Jejunalaccessishelpfulinpatientswithrecurrenttubefeedingaspiration（notoropharyngeal）orincriticallyillpatientsatriskforgastricmotilitydysfunction（e.g.,patientswithheadtrauma）.
Tolimittheriskofaspirationwithsmallbowelfeeding,thefeedingportofthenasoenterictubeorpercutaneousendoscopicjejunostomyshouldbeclosetoorbeyondtheligamentofTreitz.Severevomitingorcoughingmaydisplacesomenonsurgicaltubes,andradiographsmaybeneededtoverifythetubeposition.
Diarrheaisacommon,albeitpoorlydefinedcomplicationofenteralfeedingthathasmanypotentialcauses.Theseincludemedicationssuchasantibioticsorsorbitol-containingproducts,alteredbacterialflora,formulacomposition（includingosmolality）,infusionrate,hypoalbuminemia,bacterialcontaminationoftheenteralfluid,andphysiologicaldisturbancesrelatedtothepatient'
soverallphysicalcondition.However,studiesoftherelationshipofeachofthesefactorstodiarrheaandtubefeedingareinconclusive.Therefore,itisn'
tpossibletoprovideanyuniversalrecommendationsforpreventingoreliminatingthiscomplication.Byconsideringallpotentialetiologies,itmaybepossibletotakestepsthatwillreducediarrheainselectedsituations.
Carefulattentionmustbepaidtofluidandelectrolytemanagementtominimizeanymetaboliccomplications.
SpecializedEnteralFormulations
Althoughoneortwoenteralformulationscanmeetmostpatients'
needs,specialtyproductsmaybeusefulincertaindiseasestates.Theseincludeblenderized,lactose-containingandlactose-free,fiber-containing,elemental,andmodularproductsandspecializedfeedingssuchaspulmonaryformulas.Althoughsomeformulationshaveclearclinicalindications（e.g.,lactose-freemixturesforpatientswithlactasedeficiency）,theadvantagesofothersarelessclear.
Isotonicpolymericformulationscanmeetmostpatients'
nutritionalneeds.
Theuseofelementalformulationsshouldbereservedforpatientswithseveresmallbowelabsorptivedysfunction.
Specialtyformulationsgenerallyaremoreexpensivethanstandardformulasandhavealimitedclinicalrole;
moredataareneededtojustifytheirpracticalityandeffectiveness.
NutritionSupportTeams
Multidisciplinarynutritionsupportteamsareavaluableadjunctinthemanagementoftube-fedpatients.Thecombinedexpertiseofsuchateamlikelywillresultinbettercare,decreasedcomplications,andincreasedcost-effectivenessofenteralnutrition.
References
1.KirbyDF,DeLeggeMH,FlemingCR.AmericanGastroenterologicalAssociationtechnicalreviewontubefeedingforenteralnutrition.Gastroenterology1995;
108:
1282-1301.
AmericanGastroenterologicalAssociationTechnicalReviewonTubeFeedingforEnteralNutrition
ThisliteraturereviewandtherecommendationsthereinwerepreparedfortheAmericanGastroenterologicalAssociationPatientCareCommittee.Followingexternalreview,thepaperwasapprovedbytheCommitteeonSeptember17,1994.ItservesasthefoundationfortheAssociation'
sofficialrecommendationsasgiveninthepreviousstatement.
Nodiseaseprocessimprovessignificantlywithprolongedstarvation.Whereasshortperiods（<
7days）ofnutrientdeprivationmaybewelltoleratedbymostpatientsdependingontheirstartingpointandpresentdegreeofcatabolism,longerperiodscanbedetrimental.Duringstarvation,fatisthemajorsourceofcaloriesstoredinthebodyandismobilizedtomeetthebody'
sneeds.However,glycogenhasasmallstorageform（∼900kcal）andproteinhasnostorageformsothatduringstarvation,slowturnoverproteinssuchasmusclemustbecannibalizedforenergyandvisceralproteinsupport,whichultimatelyleadstoorganfunctioncompromise.1
Whereastubefeedinghasbeenpracticedinvaryingformsformorethan400years,technicalinnovationsduringthepast2decadeshavemadetheproceduremoreacceptabletopatientsandalesscostlyalternativetoparenteralnutrition.Recentdataontheoccurrenceofbacterialtranslocationfromanenterallydeprivedgastrointestinaltracthavefocusedrenewedattentiontousethegastrointestinaltractassoonasissafelypossible.2Gastroenterologistswithvaryingamountsoftraininginnutritionsupportareaskedtomanagepatientsreceivingenteralnutri
升级会员 